Board and Care Fire,
Harveys Lake, Pennsylvania
10 People Killed
Tuesday, May 13, 1997
NFPA Report by Ed Comeau
Summary
On Tuesday, May 13, 1997, a fire occurred at a board and
care facility in Harveys Lake, Pennsylvania. State fire
investigators determined that the fire most likely started
on a screened-in porch. Investigators determined that the
fire was caused by disposal of smoking materials on the
screened-in porch area of the building. The fire killed ten
residents and injured three others. The building was heavily
damaged by the fire, and the property loss was estimated at
$270,000.
The facility was a two-story plus basement, wood-frame
structure with several additions that had been made over
time, which increased the size of the building. Fire
protection features included a fire alarm system with smoke
detectors and heat detectors, and fire extinguishers.
Interior stairways were enclosed. Steel doors with
self-closing devices protected openings to the stairways;
however, the self-closing device on one of the stairway
doors was deactivated. Wall and ceiling finishes were
noncombustible. The facility was not equipped with an
automatic sprinkler system.
The first floor contained three doors to the exterior at
grade. One door was on the south side off of the screened-in
porch to the exterior. The two other doors were on the west
side of the building. One on the southwest corner was used
as well as one from the kitchen on the northwest corner
.
The second floor was accessible by two interior stairways
on the west side of the building. The stairway on the
southwest side led to a small foyer area that was accessible
to the southwest door on the first floor. The stairway on
the northwest side led to a small open area at the door on
the northwest side at the kitchen. This door was not
identified in the second floor evacuation plan. An exterior
stair way on the north side of the building was accessible
from the second floor by traveling through a bedroom.
The interior stairway identified for occupant egress in
the evacuation plan was separated from the rest of the
structure, however, the door- closer on the door at the
bottom of the stairway was disabled and the door open at the
time of the fire. The exterior stairway was only accessible
by passing through a bedroom.
One staff member and 21 residents were in the building at
the time of the fire. The 21 occupants of the building
ranged in age from 58 to 99 with varying medical needs and
mental capacities. State regulations do permit individuals
identified as immobile to be housed in personal care
homes.
Investigators were not able to determine the type and
frequency of fire safety training that had been provided for
residents and staff.
Investigators determined that the fire started on an
exterior screened-in porch that was being used as a smoking
area. Once ignited, the fire involved the combustible
materials used in the construction of the porch, combustible
exterior siding for the building, and combustible
furnishings. Investigators believe that the fire broke large
windows between the porch and the interior of the building
allowing the fire to enter one bedroom and a living
room.
According to investigators, the staff member was in the
kitchen completing paperwork when the building alarm
sounded. Based on previous false alarms, the staff member
attempted to reset the building alarm system. When the alarm
system did not reset, the staff member silenced the alarm
trouble and the panel trouble indicators. It was at this
time that the staff member was informed of a fire by a
resident. After confirming the fire, the staff member
returned to the kitchen and notified the rest of the
residents by activating the drill switch on the alarm panel.
The staff person then took action to assist in the
evacuation of residents.
At approximately 9:10 p.m. a call was placed to the
Harveys Lake Fire Department reporting a fire at the board
and care facility. At 9:10 p.m., a telephone call was
received at Back Mountain Control (Regional 911 answering
point) from a neighbor whose house is located south of the
building and through a thickly wooded area. She told the
dispatcher that the board and care facility was fully
involved. The Harveys Lake Fire Department was immediately
dispatched with the fire chief responding directly from his
home. During this time numerous 911 calls were received at
Back Mountain Control.
Fire fighters began arriving on the scene about 3 minutes
later and they found that the building was heavily involved
in fire. Many residents had escaped by the time that fire
fighters arrived, and they reported to fire fighters that
others were still in the building. Despite the severity of
the fire, which prevented fire fighters from entering many
areas, fire fighters were able to rescue six residents. Four
of the residents who had been rescued, later died in the
hospital. After the fire was extinguished, the bodies of six
residents were found in various locations throughout the
building. Preliminary information indicated that all
residents died of smoke inhalation.
Investigators did not specify the materials that were
first ignited by the smoking materials. It is believed that
combustible furnishings on the front porch were some of the
initial fuels that contributed to the fire travel around the
outside of the building. The fire grew quickly, spreading
down the ceiling of the porch in each direction. The fire
then broke through one of the windows between the interior
of the building and the porch. Once in the interior of the
building, the fire traveled through open doorways and the
open door to the stairway, cutting off the primary exits
from the building. The fire also traveled up through the
walls to the second floor. Fire and products of combustion
also continued to spread along the ceiling of the open
living room on the first floor and into the open dining
room. On the second floor, fire and products of combustion
moved through the bedroom and out into the hall. Fire
eventually broke through to the roof construction over the
dining room and traveled throughout the combustible
concealed space causing collapse of the roof structure over
the dining area.
Based on the NFPA's investigation and analysis of this
fire, the following factors were considered to have
contributed significantly to the loss of life and property
in this incident:
- Improper use or disposal of smoking materials
- Ineffective resident and staff action
- Inadequate means of egress
- Open fire doors in vertical fire separations
- Room doors with inadequate fire resistance
ratings
- Lack of automatic door closing devices on individual
room doors
- Lack of automatic sprinkler system
The Harveys Lake incident is the fourth since 1991 where
the evacuation capabilities of the residents has had a
direct impact on the number of casualties. The assumption
that the individual's have the abilities to independently
process the degree of danger of a situation and act
accordingly has also been identified as a factor in the
following fires:
- Colorado Springs, CO 1991 9 fatalities
- Broward County, FL 1994 5 fatalities
- Shelby County, TN 1996 4 fatalities
- Laurinburg, NC 1996 8 fatalities
All of the seven significant factors identified in this
incident as contributing to the loss of life are issues that
are addressed in NFPA documents. A change in any one of them
could potentially have had the ability to reduce the number
of deaths that occurred at this fire.
Within the past 15 years, NFPA has investigated 11 fires,
which have caused the deaths of 83 people. The type of board
and care facilities in which these deaths have occurred
range from those that house elderly patients to those that
house mentally challenged people. With the potential
increase in the number of these facilities, it is more and
more important that an adequate level of fire protection is
provided to ensure protection of the people living in them
and to avoid future tragedies.
There have been seven fatal board and care fire
investigated by NFPA since December, 1984. These seven
incidents have resulted in a total of 50 fatalities over a
period of 3-1/2 years. The other six incidents include:
A related article on board
and care fires was written by Ed Comeau for NFPA Journal
and can also be seen on-line.
©
1997 National Fire Protection Association, Quincy, MA
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